Their comprehensive analysis of the results of medical management of 312 survivors triaged to the Gregorio Marañón University General Hospital GMUGH provides several important lessons, a
Trang 120 GMUGH = Gregorio Marañón University General Hospital.
Critical Care February 2005 Vol 9 No 1 Frykberg
The report by Peral Guiterrez de Ceballos and colleagues [1]
is a timely, well written, and informative contribution to our
growing body of knowledge of disaster medicine, as well as
an appalling confirmation of the horrors of the senseless and
vicious scourge of terrorism that now afflicts the world Their
comprehensive analysis of the results of medical
management of 312 survivors triaged to the Gregorio
Marañón University General Hospital (GMUGH) provides
several important lessons, and raises several questions, for
medical providers around the world who are increasingly
faced with the necessity of learning how to plan and
implement an effective response to such a daunting
challenge
The authors confirmed the many consistent patterns to be
expected following terrorist bombings, which virtually every
other published series has documented [2,3] The great
majority of immediate survivors (1789/1885 [95%]) were not
critically injured As the authors state, this is best explained
by the selection bias caused by the immediate death of most
of those with critical injuries Although it appears quite
favorable that 14 of these 1885 immediate survivors (0.74%)
subsequently died, it is important to recognize that this is
deceptive because most casualties were not at all at risk for
death The death rate was correctly expressed in this report
as a percentage of only the critically injured casualties who
were truly at risk for death, and among whom all deaths
occurred, resulting in a much heftier ‘critical mortality’ rate of
17% (14/82) This is a more accurate reflection of the quality
of medical care given in such a mass casualty setting, and is
a more accurate standard for comparison with other similar
bombings This critical mortality rate falls well within the
range of all other terrorist bombing disasters, and lends itself
to quality improvement analysis The authors should be
commended for applying the established objective measures
of injury severity (Injury Severity Score, Acute Physiology and
Chronic Health Evaluation II) to their patient population to allow this determination I do agree that the two early emergency room deaths should be included in this figure because these patients were exposed to medical care The injury patterns in this event were also typical of bombing disasters Head, chest, abdominal, traumatic amputation and blast lung injuries predominated among the critically injured survivors, being the most common contributors to death; musculoskeletal and soft tissue wounds predominated among those who were not critically injured Eardrum perforations and eye injuries were quite common but did not cause life-threatening problems
Over-triage, or the assignment of noncritically injured victims
to immediate medical evaluation and hospitalization, was also predictably and typically high, in view of the large load of casualties with noncritical injuries At the GMUGH, 91 out of the 312 survivors evaluated (29%) were hospitalized, but 62
of these were not critically injured, yielding a substantial over-triage rate of 68% The danger with this degree of over-over-triage
is in the potential to overwhelm limited medical resources and prevent that minority with critical injuries from being quickly identified and treated, thus increasing critical mortality Although the authors did not believe that this interfered with their treatment, their 17.2% critical mortality at this level of over-triage falls well within the linear relationship demonstrated between over-triage and critical mortality [3] Furthermore, an objective analysis of the deaths may reveal preventable delays in diagnosis and treatment that were not immediately perceived For instance, one of the deaths was due to a ruptured thoracic aorta in a patient who had been fully evaluated and already admitted to the intensive care unit; could this injury have been identified earlier and repaired, and could it represent an oversight caused by the confusion of sorting out so many noncritical victims? These considerations
Commentary
Terrorist bombings in Madrid
Eric R Frykberg
Professor of Surgery, University of Florida College of Medicine, Jacksonville, Florida, USA
Corresponding author: Eric R Frykberg, editorial@ccforum.com
Published online: 3 November 2004 Critical Care 2005, 9:20-22 (DOI 10.1186/cc2997)
This article is online at http://ccforum.com/content/9/1/20
© 2004 BioMed Central Ltd
See Review, page 104
Trang 2Available online http://ccforum.com/content/9/1/20
emphasize the importance of triage accuracy, and of
preventing, as much as possible, the arrival of so many
noncritical victims to a definitive care hospital by performing
triage first at outside sites before allowing them to inundate
the hospital
The massive response of the public to donate blood
following the Madrid bombings is another very typical pattern
seen in such disasters However, it is a very unfortunate
response that represents a misguided attempt to help on the
part not only of the lay public but also of the medical
community and media, and must be curbed in future events
It is well established that very little blood is needed in these
disasters; again, only a small minority are critically injured,
and only a small percentage of these ever need blood
Following the New York City World Trade Center disaster of
9/11, more than 20,000 units of donated blood had to be
discarded unused This was confirmed by the authors of this
paper in reporting only 104 units given to patients out of
several thousand donated units The problem with this is that
the hospital can be paralyzed by the crowds lining up to give
blood, diverting critically scarce hospital resources and
personnel away from those victims who are most in need,
leading to potentially unnecessary harm to these victims This
altruistic response of the public should be more effectively
channeled to other blood-banking facilities outside hospitals
where they will not interfere with triage and treatment of
casualties, and the media should be educated to avoid
directing the public to such futile activity
Nonetheless, the outstanding performance of the authors,
their coworkers, and the entire city of Madrid in the hours and
days following this tragedy must be recognized There
appeared to be a reasonably prompt and effective initial
triage and distribution of casualties among all available
hospitals by the prehospital first responders, indicated by the
fact that GMUGH – the closest facility – was not inundated
with the majority of casualties, as has occurred in so many
other similar events The most seriously injured were
apparently transported to the most appropriate hospitals with
the greatest resources With virtually no warning, GMUGH
performed all of the appropriate procedures to maximize their
surge capacity for incoming victims (clearing of emergency
room, intensive care unit and floor beds, and canceling all
surgery in the operating rooms); this is a valuable lesson, and
all hospitals should include such actions in their disaster
plans The absence of any apparent under-triage – deaths
due to critical injures being overlooked and assigned to
delayed care – suggests good triage and is quite consistent
with the published literature The high number of blast lung
injuries in survivors also suggests rapid evacuation and
treatment, and the low mortality (2/17 [12%]) among these
survivors indicates excellent intensive care for such very
difficult cases The relatively low immediate death rate of
8.6% (177/2062), as compared with most other terrorist
bombings, is certainly due in part to the fact that this was an
open air blast that was rapidly dissipated over a short distance, without any building collapse or shrapnel causing serious penetrating wounds However, the rapid response, and evacuation and treatment of survivors who otherwise may have died with longer delays could undoubtedly be another contributing factor to this result
The authors discuss the merits of developing a trauma system in Spain to augment and serve as the basis for disaster readiness on a large scale, a concept that we advocate in the USA [4] Trauma centers have a ready-made infrastructure in place for disaster responses, including the personnel and resources for managing multiply injured patients in large numbers They also have most of the necessary liaisons with public health, law enforcement, the media, prehospital services, search and rescue, local government, and transportation assets for evacuation Most importantly, they have around-the-clock surgical availability
This is essential in those terrorist attacks that are, by far, the most likely to occur if we are to heed history as well as current events, namely bombings and shootings, with bodily injury the most likely result In fact, a state-wide system has already been implemented on this principle in Connecticut, using the state-wide trauma centers in a coordinated network
of function, which serves as a model of what can be done in any region or country [5]
There are several cogent questions that remain unresolved with this report, but only a full analysis of the entire event, looking at the combined experience of all involved hospitals, can answer these All 14 deaths among the critically injured survivors should be thoroughly analyzed to identify any preventable problems in management that could be improved
in future events Were there any hospitals in Madrid that were not used, which could have helped to lighten the load on the others? If so, then a better system of casualty distribution should be planned It would be of interest to know how the existing disaster plan of GMUGH, and for the entire city of Madrid, held up through this event Was it at all helpful?
Were any revisions made as a result of this experience to improve the disaster response in the future? It has been recommended by several experts that the closest hospital to the disaster scene, as GMUGH was, should be used as a casualty collection point and initial triage station for distribution of casualties to the other available hospitals, rather than as just another treatment facility, as it was in this event What led to this decision? What procedures were used to assure security of the hospital and prevent it from being overrun with worried well victims and families, and how was the media handled? These considerations are important points for all of us to learn
Finally, the authors must be congratulated for their foresight and commitment in performing the huge but essential task of putting together all these data and submitting a report for publication so that the rest of the world can learn from their
Trang 3Critical Care February 2005 Vol 9 No 1 Frykberg
valuable experience Unlike most of medicine, true mass casualty disasters are very rare, and approaches to planning and management are very different from our everyday practice Therefore, most of us will never learn how to deal with such incidents, and the same mistakes will be repeated each time unless we take to heart the experiences of those who have been confronted with a disaster With the wealth of published experience now available to us, which this reports nicely augments, it is clear that there are definite patterns of injury, behavior, and impediments to care that follow all terrorist bombings, and – to a great extent – disasters of all kinds as well Once patterns are identified, there is
opportunity to plan and cope, and discard the notion that these are acts of God that cannot be predicted or planned for The biggest barrier to effective learning now is the apathy and complacency that plagues so much of our medical community, precisely because of the rarity of these events
We must all become involved in disaster planning at our own hospitals and in our own communities, and contribute to the education and motivation of our colleagues if success is to
be achieved
Competing interests
The author(s) declare that they have no competing interests
References
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Sanz-Sanchez M, Martin-Llorente C, Guerrero-Sanz JE: 11 March 2004: The terrorist bomb explosions in Madrid, Spain – an analysis of the logistics, injuries sustained and clinical
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